Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00291295 Unannounced Monitoring 06/17/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the main bathroom's bathtub measured at 125.6 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. On June 17, 2026, an unannounced inspection was initiated by Licensing. During the inspection, the water temperature in the main bathroom's bathtub was measured at 125.6°F. Regulation 6400.68(b) provides that the hot water temperature in bathtubs and showers may not exceed 120°F. Since this provider does not have full control of water temperature mechanisms, the apartment complex maintenance staff was contacted immediately. They responded within 2 hours and turned the temperature to 118 degrees. 07/17/2026 Implemented
6400.112(c)The fire drill record for the fire drill conducted on 5/4/20 at 5:47 PM did not include or indicate the year in which the fire drill was conducted.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill form was reviewed with the Program Supervisors and Management team on 9/16/26 and they were reminded that all required information must be completed on the fire drill record, including the full date with month, day, and year, time of the drill, evacuation time, exit route used, problems encountered, and whether the fire alarm or smoke detector was operative. See attachment 1. Program Supervisors will review each completed fire drill record for accuracy and completeness and initial the form to verify that all required information is present. 09/16/2026 Implemented
6400.141(c)(7)Individual #1 had an Annual gynecological examination on 4/10/25 and the office visit form notes "Breast exam not done." Individual #1's next annual gynecological examination occurred on 6/10/26 which exceeds the requirement. The 6/10/26 examination was stopped due to Individual #1 being uncooperative.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. According to 6400.141.c(7) The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. On the date of the inspection the Reviewer observed that Individual #1 had an Annual gynecological examination on 4/10/25 and the office visit form notes "Breast exam not done." Individual #1's next annual gynecological examination occurred on 6/10/26 which exceeds the requirement. The 6/10/26 examination was stopped due to Individual #1 being uncooperative. The individual was immediately counseled, and such counseling was documented in the individual's record. 06/18/2026 Implemented
6400.144Individual #1 had a Primary Care Physician appointment on 8/8/25 and the after visit summary noted an October 10.20.25 Neurology appointment in the "What's Next section" for upcoming appointments for Individual #1. There is no record or documentation that Individual #1 attended this appointment. When the Licensing Representative inquired about the appointment, the agency reported that Individual #1 missed that appointment, and it was rescheduled for 12/10/25. Individual #1's 12/10/25 Neurology appointment after visit summary noted to return in about 4 months (4/10/2026). There is no record or documentation that Individual #1 attended this appointment. Individual #1 had a dental examination on 9/20/24 and the form noted a follow up in 6 months 3/24/25. There is no record of this appointment as the next appointment in the file is 9/25/25. The 9/20/24 dental appointment noted under physician and consult orders oral surgery referral given for extraction of #25. There is no documentation/record that this occurred.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. 6400.144 Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 had a Primary Care Physician appointment on 8/8/25 and the after-visit summary noted an October 10.20.25 Neurology appointment in the "What's Next section" for upcoming appointments for Individual #1. There is no record or documentation that Individual #1 attended this appointment. When the Licensing Representative inquired about the appointment, the agency reported that Individual #1 missed that appointment, and it was rescheduled for 12/10/25. Individual #1's 12/10/25 Neurology appointment after visit summary noted to return in about 4 months (4/10/2026). There is no record or documentation that Individual #1 attended this appointment. Individual #1 had a dental examination on 9/20/24 and the form noted a follow up in 6 months 3/24/25. There is no record of this appointment as the next appointment in the file is 9/25/25. The 9/20/24 dental appointment noted under physician and consult orders oral surgery referral given for extraction of #25. There is no documentation/record that this occurred. The individual has since died so no follow-up will happen with the individual but changes too policy/job description has been updated as shown in the next section. 06/26/2026 Implemented
6400.51(b)(2)There was no record or documentation that Staff #1 received orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the documents/ records provided via email to the Licensing representative.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. There was no record or documentation that Staff #1 received orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the documents/ records provided via email to the Licensing representative. Staff 1 was retrained immediately. 06/19/2026 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had psychiatric medication reviews on 7/25/25, 10/13/25, 12/9/25, and 3/6/26, and 6/1/26, and the form used for all of these appointments did not include did not include documentation of the reason for prescribing the medication, and the need to continue the medication and the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.6400.165 (g) If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documenting the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had psychiatric medication reviews on 7/25/25, 10/13/25, 12/9/25, and 3/6/26, and 6/1/26, and the form used for all of these appointments did not include documentation of the reason for prescribing the medication, and the need to continue the medication and the necessary dosage. A clinical review was scheduled immediately. 06/22/2026 Implemented
SIN-00280051 Renewal 12/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)An application for a PA criminal history check shall be submitted to the State Police within 5 working days after the persons date of hire. Staff #3's date of hire was 8.26.25 and her background check was not completed until 9.11.25. This exceeds the time. An application for a PA criminal history check shall be submitted to the State Police within 5 working days after the person's date of hire. Staff #5's date of hire was 3.26.25 and her background check was not completed until 4.4.25. This exceeds the time. An application for a PA criminal history check shall be submitted to the State Police within 5 working days after the persons date of hire. Staff #4's date of hire was 11.11.24 and her background check was not completed until 11.22.24. This exceeds the time.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. In accordance with 6400.21 (a), an application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Staff #3's date of hire was 8.26.25, and her background check was not completed until 9.11.25. This exceeds the time. Staff #4's date of hire was 11.11.24 and her background check was not completed until 11.22.24. This exceeds the time Staff #5's date of hire was 3.26.25 and her background check was not completed until 4.4.25. This exceeds the time. On January 7, 2026, the supervisor reviewed the requirements of 6400.21 (a) with the Orientation Coordinator to be sure that she understands the requirement (see attachment 8) 01/07/2026 Implemented
6400.67(b)Surfaces shall be free from hazards. The dryer in the apartment had a golf ball size of lint in the trap at the time of inspection. This is a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.6400,67(b) states that floors, walls, ceilings and other surfaces shall be free of hazards. At the time of inspection (December 18, 2025), there was a golf-ball-sized accumulation of lint in the home's dryer's lint trap. This accumulation of lint posed a fire hazard within the home. This violation was corrected on December 22, 2025, when a house supervisor was directed to go out to check and clean each home's dryer lint trap. Of the 13 LVHS homes, two additional violations were cited by LVHS supervisory staff. The lint trap was cleaned in both of these and the original cases. See the documentation of the Supervisor Inspection Form (Fire Hazard), as attachment 1. 12/22/2025 Implemented
6400.46(a)Direct service worker shall be trained in fire safety before working with individuals. Staff #3 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. Staff #4 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. Staff #5 did not have documentation to reflect that training was completed prior to working with individuals in fire safety.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered (6400.46 (a). During the ODP site inspection on December 18, 2025, a violaton was issued for the following: Staff #3 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. Staff #4 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. Staff #5 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. The staff was immediately trained on fire safety (December 22, 2025). See attached sign-off sheets for fire safety training. 12/22/2025 Implemented
6400.46(b)Direct service worker shall be trained in fire safety annually by a fire safety expert. Staff #4 did not have her annual fire safety training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a) (6400.46 (b). Staff #4 did not have documentation to reflect that training was completed prior to working with individuals in fire safety. The staff was immediately trained on fire safety (December 22, 2025). See attached sign-off sheets for fire safety training. 12/22/2025 Implemented
SIN-00222441 Renewal 03/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Floors, walls, ceilings and other surfaces are not in good repair. The door frame in Individual #2's bathroom was missing the molding on the side of the frame where the door latch is located. The sliding doors located on the laundry area are broken and falling off.Floors, walls, ceilings and other surfaces shall be in good repair. Provider has implemented a Quality Assurance tool to ensure property is in good repair and shape. This tool will be completed by the Program Manager monthly and forwarded to Director for review. (molding and sliding door repaired -CH 5/5/23) 04/01/2023 Implemented
6400.67(b)Floors, walls, ceilings, and other surfaces are not free from hazards. The door frame around Individual #1's bedroom and the bathroom located off of Individual #2's bathroom have peeling paint. Floors, walls, ceilings and other surfaces shall be free of hazards.Provider has implemented a Quality Assurance tool to ensure property is in good repair and shape. This tool will be completed by the Program Manager monthly and forwarded to Director for review. (paint repaired -CH 5/5/23) 04/01/2023 Implemented
6400.141(a)Individual #2 did not have a physical examination within 12 months prior to admission. Individual #2 was admitted to the program on 2/8/22 and did not have a physical examination completed until 4/21/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. 04/01/2023 Implemented
6400.141(c)(4)Individual #2 has not had an annual hearing examination completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. 04/01/2023 Implemented
6400.142(a)Individual #2 has not had a dental examination completed since admission on 2/8/22.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. (dental examination scheduled 5/8/23 -CH 5/5/23) 04/01/2023 Implemented
6400.142(f)Individual #2 does not have an annual dental hygiene plan.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. (dental appointment scheduled -CH 5/5/23) 04/01/2023 Implemented
6400.144Health services including scheduling of follow up medical appointments has not been planned for. Individual #2's Primary Care Physician recommended follow up for hearing, with Gastroenterology for a colonoscopy and for follow up on 4/21/22. There have been no appointments scheduled to complete the follow up.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Program Specialist and Program Manager will track required medical appointments and ensure appointments are made according to need and requirements. (colonoscopy completed 4/24/23 - CH 5/5/23) 04/01/2023 Implemented
6400.46(b)Staff #6 received fire safety training on 5/5/22, however there is no documentation to support that the training was completed by a fire safety expert and included the training areas specified in subsection (a).Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Provider has contracted with Allentown Fire Department to facilitate the annual fire training. Captain Christopher will be facilitating the training on May 10 & May 17. 06/01/2023 Implemented
6400.50(a)Records of training for annual training in Recognizing and Reporting Incidents dated 12/9/22 for Staff #6 did not include the length of training. Records of training for fire safety training completed on 5/5/22 for Staff #6 did not include the training source and content of training. Staff #6 received a Certificate of Completion from the American Red Cross for Adult First Aid and CPR on 4/29/22. The certificate did not include the length of training.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Providers trainer has updated the training sign in sheet to reflect more detail, including the length of time and training content. 05/01/2023 Implemented
6400.52(c)(2)Staff #6 did not complete annual training in the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-10225-5102), the Child Protective Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Provider has created a yearly calendar to reflect all necessary yearly trainings, as well as "new hire orientation" trainings. (staff trained 4/17/23 -CH 5/5/23) 04/01/2023 Implemented
6400.195(a)Individual #2 does not have a bedroom door. Individual #2's Individual Support Plan (ISP) states "CURTAIN AS DOOR TO BEDROOM: A FABRIC CURTAIN TO BE USED IN PLACE OF A WOODEN OR METAL DOOR TO PROTECT THEM IN THE EVENT OF A BEHAVIORAL EPISODE." Individual #2's right to lock the bedroom door is being denied due to behavioral concerns. There is no component addressing behavior supprt being reviewed and approved by a human rights team for the use of restrictive procedures.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.A restrictive procedure plan was created to reflect the need for the door being of the hinges. This plan has been reviewed and approved by the Human Rights Committee. 04/14/2023 Implemented
SIN-00206695 Renewal 05/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature was measured at 135.8 degrees Fahrenheit in the bathroom located off the Individual's bedroom at the time of inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. The property manager of the apartment complex was notified of the water temperature. A request by the program manager was made to lower the temp. Staff immediately posted notes near the sinks/tub to ensure everyone was made aware to closely monitor the water until it was adjusted. Property Manager was able to come out the following morning and water temp adjusted. After two temp checks by program manager, postings were removed 08/01/2022 Implemented
6400.166(a)(11)Individual #1 is currently prescribed 14 daily medications which are listed on the current Medication Administration Record (MAR) and there is not a diagnosis or purpose recorded on the MAR for any of the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Provider followed up with primary care physician to have script rewritten to include dx. Staff followed up with pharmacy to secure a new label for MAR. Meeting held on May 9, 2022 to address the concern, administrative assistant and med trainer immediately followed up with the primary care physicians, pharmacy and staff within the home to ensure all labels included all line items listed on reg 6400.166(a). 05/09/2022 Implemented